Implementation Tips

Effective and timely identification of errors and system failures remains a rather challenging undertaking for many healthcare professionals due to fear of litigation, emotional burden associated with adverse events, conflicting perspectives of various stakeholders, lack of trust, inadequate organizational structures, systems and processes, lack of leadership support, and deficient performance measures. The RCA needs to be conducted thoughtfully, systematically and in a non-punitive manner in order to generate useful information, maximize organizational learning, achieve greater understanding of the vulnerabilities in the system, and catalyze high-impact changes that will lead to the safest and highest quality of patient care. Successful implementation of the RCA process depends on continual leadership support and broader organizational commitment to building a culture of safety. In addition, the RCA has to be adapted to the specific organizational circumstances while taking into consideration the following guidelines:

  • Select team members with complementary knowledge, skills and abilities
  • Involve staff who are familiar with the situation and associated processes
  • Act with integrity, establish ground rules and address potential conflicts of interest
  • Form genuine partnership with all individuals involved in the event
  • Demonstrate clear purpose and convey a sense of urgency
  • Promote transparency and encourage people to express opposing viewpoints
  • Convey necessary information in the context of target audience
  • Eliminate the use of blaming, insensitive language
  • Facilitate both creative and analytical thinking
  • Approach complex issues with flexibility, curiosity and open-mindedness
  • Demonstrate resilience in the face of adversity
  • Examine systemic issues from different points of view
  • Contain subjective interpretations and prevent “jumping to conclusions”
  • Avoid giving excessive attention to the most conspicuous causal factors
  • Recognize and minimize the influence of cognitive biases
  • Challenge assumptions that limit opportunities for improvement
  • Make decisions based on accurate and appropriate data
  • Consider the potential impact of alternative solutions
  • Emphasize the importance of testing before full implementation of the selected solutions
  • Develop balancing metrics to assess any unintended outcomes of the selected solutions
  • Do not support inadequate solutions to the problem just to preserve team cohesiveness
  • Focus on improving critical systems and processes
  • Design and apply effective error proofing methods
  • Provide timely communication on the corrective and preventive actions being taken
  • Ensure alignment with the strategic goals of the organization
  • Dedicate a reasonable amount of time to complete the work
  • Leverage existing quality management and process improvement resources
  • Ensure broad participation in planning, testing and implementing the change
  • Protect confidential and sensitive information
  • Provide ongoing support to the staff and patients impacted by the event
  • Be candid about remaining problems and challenges
  • Follow applicable legislative and regulatory requirements
  • Involve patients and families as an integral part of quality improvement efforts
  • Apply the RCA process fairly and consistently across the organization
  • Develop and deliver the RCA training program for organizational leaders
  • Promote effective dissemination of lessons learned within and outside the organization
  • Always deliver on commitments and celebrate accomplishments